(Rev. February 2006) for United States Tax Withholding OMB No. 1545-1621
䊳 Section references are to the Internal Revenue Code. 䊳 See separate instructions.
Department of the Treasury
Internal Revenue Service 䊳 Give this form to the withholding agent or payer. Do not send to the IRS.
3 Type of beneficial owner: Individual Corporation Disregarded entity Partnership Simple trust
Grantor trust Complex trust Estate Government International organization
Central bank of issue Tax-exempt organization Private foundation
4 Permanent residence address (street, apt. or suite no., or rural route). Do not use a P.O. box or in-care-of address.
City or town, state or province. Include postal code where appropriate. Country (do not abbreviate)
City or town, state or province. Include postal code where appropriate. Country (do not abbreviate)
6 U.S. taxpayer identification number, if required (see instructions) 7 Foreign tax identifying number, if any (optional)
SSN or ITIN EIN
8 Reference number(s) (see instructions)
Sign Here 䊳 Signature of beneficial owner (or individual authorized to sign for beneficial owner) Date (MM-DD-YYYY) Capacity in which acting
For Paperwork Reduction Act Notice, see separate instructions. Cat. No. 25047Z Form W-8BEN (Rev. 2-2006)
Printed on Recycled Paper